Perinatal tuberculosis and its public health impact: a case report.

Tuberculosis was initially unrecognized in a pregnant 26-year-old woman from Mexico. The diagnosis was first considered in this mother 24 days postpartum, when her newborn was admitted in shock with congenital tuberculosis. Had a high index of suspicion for tuberculosis been present during the early course of the patient's care or had she been tested on a routine basis because she was a member of a high-risk group, the continued exposure of 7 family members and the acute exposure of 293 healthcare workers and newborns in three tertiary-care centers could have been minimized or avoided entirely. We wish to emphasize the often elusive features of this diagnostic setting and the public health consequences of delayed recognition resulting in a massive recall effort. Unfortunately, only two thirds of the exposed infants were successfully recalled and skin tested. We identified one skin test conversion in a health-care worker.

Rhodococcus species fatal infection in an immunocompetent host.

A 24-year-old woman had fatal pneumonia-associated adult respiratory distress syndrome caused by Rhodococcus species. Histological examination of lung biopsy tissue showed intracellular coccobacillary microorganisms. Antimicrobial susceptibility tests on the patient's blood isolate showed that it was resistant to clindamycin and norfloxacin but susceptible to several other antimicrobial agents. Also, the isolate's biochemical reactions and pattern of RNA gene-containing restriction fragments were significantly different from those of the 20 recognized Rhodococcus species, suggesting that this patient's infection was caused by an as yet uncharacterized Rhodococcus species. Of the 17 human cases of nonequi Rhodococcus species infection reported to date (including the current case), nine patients were immunocompetent, five had disseminated infection, and four died. Further studies will be required to unequivocally establish the species status of this patient's Rhodococcus isolate biochemically and genetically.

Congenital scalp defects and vitreoretinal degeneration: redefining the Knobloch syndrome.

An apparently autosomal recessive syndrome of hereditary vitreoretinal degeneration (VRD) with retinal detachment, high myopia, and congenital encephalocele was described in 1971 by Knobloch and Layer [J Pediatr Ophthalmol 8:181-184]. Clinical confirmation of the presence of encephaloceles was lacking, and no neuropathologic studies were reported. We have evaluated a similarly affected family with 2 sibs with high myopia, VRD, and occipital scalp defects. Histologic examination of the scalp defects showed heterotopic neuronal tissue in both instances. The older girl has had a unilateral retinal detachment. Her other eye and both eyes of the younger sib have so far been treated successfully with prophylactic retinal cryotherapy. Both children have normal to above normal intelligence. The family reported by Knobloch and Layer [1971] and the sibship herein described appear to represent a distinct autosomal recessive trait. Analysis of the associated defects suggests an underlying defect in early cephalic neuroectodermal morphogenesis. Data from these families imply that congenital occipital scalp defects rather than true encephaloceles may, as is true in some cases of Meckel syndrome, accompany Knobloch syndrome. The presence of a congenital midline scalp defect should alert the clinician to possible underlying central nervous system and/or ocular pathology and should lead to consideration of further diagnostic evaluations and prophylactic measures.

Is eosinophilic ureteritis an entity? 2 case reports and review.

The characteristics of eosinophilic ureteritis and idiopathic segmental ureteritis are sufficiently overlapping and so uncommonly reported as to raise a nosological issue. In an attempt to address that question, we compared 2 new cases and 8 previous reports of eosinophilic ureteritis with a series of 21 idiopathic segmental ureteritis patients. One of our patients also had renal pelvic involvement, while 1 is the youngest (3 years old) patient reported and the first instance of bilateral eosinophilic ureteritis. Our review found that eosinophilic ureteritis largely occurs in atopic or hypereosinophilic syndromes, often with a traumatic history. Eosinophilic and idiopathic segmental ureteritis causes ureteral obstruction due to mural involvement. However, eosinophilic ureteritis never forms an intraluminal mass and is not associated with mucosal ulceration. In addition, we found no case reported with features that bridge the 2 conditions. We conclude that the clinical and pathological features of eosinophilic and idiopathic segmental ureteritis are sufficiently distinct to separate the 2 conditions.

Pathologic bronchial vasculature in a case of massive hemoptysis due to chronic bronchitis.

The cause of bleeding in a patient with recurrent massive hemoptysis was not apparent after bronchoscopy and gross examination of the lobectomy specimen. Histologic submission of all major bronchi uncovered dilated, tortuous bronchial arteries just below the bronchial mucosa with sites of both current and healing arterial rupture. This bronchial arterial abnormality is common to several chronic pulmonary diseases, but is rarely diagnosed as a cause of massive hemoptysis. Careful pathologic examination of major bronchi in the setting of hemoptysis of unknown causation is recommended.

Solitary blood cultures as a quality assurance indicator.

For patients with suspected bacteremia, at least two separate blood cultures are recommended to achieve maximum sensitivity and to properly interpret results. Since a single blood collection may signify an improper procedure with serious consequences if the diagnosis of blood stream infection is missed, we investigated this problem with studies at three teaching hospitals (A, B, and C) and by a survey of 38 other hospitals. The incidence of solitary blood cultures ranged from 1 to 99% (median 26%) at the surveyed institutions. Among the cases investigated at hospitals B and C, between 10 and 30% of solitary blood cultures were not clinically indicated, while most of the others were caused by the physician not knowing that one culture was insufficient or by failure to complete the diagnostic plan. Focused concurrent intervention at hospital B was associated with reductions in solitary blood cultures from 40.0 to 24.6% (p = 0.045) and a decline in those not indicated from 38.1 to 12.5% (p = 0.192). Global educational efforts at hospital A were associated with a decrease in solitary blood culture rates from 52 to 37% (p = 0.016). These results show that blood culture practice varies widely among institutions in spite of consensus recommendations for proper specimen collections. We estimate that, nationwide, up to 18,000 etiologic diagnoses of bacteremia are missed annually because of this problem. Monitoring institutional solitary blood cultures is recommended as a test utilization indicator and as the basis for improving blood culture practice.

Negative BACTEC 460-TB cultures. How long to incubate?

Current guidelines for all mycobacterial cultures require at least eight weeks of incubation. Thirty months' experience of 3,662 specimens with the BACTEC TB was reviewed. At the end of four weeks of incubation, 96.8% of the 343 isolates were detected and by the end of the fifth week, 98.8%. The additional three weeks' incubation cost estimates were $1,016.20 for 92 hours of labor. Of the four late yields, only one may have had any clinical significance. The authors' recommendation is that the eight weeks' incubation guidelines for all mycobacterial cultures and especially for the BACTEC TB be comprehensively reviewed to determine clinical relevance and cost effectiveness of incubation of the BACTEC TB vial beyond five weeks.

Nontuberculous mycobacterial adenitis of childhood. The ten-year experience at a community hospital.

An increased occurrence of nontuberculous mycobacterial adenitis was observed in children admitted to the Tucson Medical Center for adenitis between 1979 and 1983. All infections were due to Mycobacterium avium-intracellulare complex (MAI). All isolates were obtained from children less than 3 years old and with symptoms of two months or less. Children with negative cultures tended to be older, had a longer interval of lymphadenopathy, and had larger glands. Factors that may have caused the separation of our two groups and the high prevalence of MAI are addressed herein. Only earlier suspected diagnosis and application of tuberculosis screening studies can define the true prevalence of MAI disease in childhood.

Punctate intranodal gold deposits simulating microcalcifications on mammograms.

Some axillary lymph nodes are frequently seen on mammograms. Rarely, such nodes will demonstrate opacities that appear to be multiple punctate calcific deposits. The literature is of little guidance as to the meaning of this appearance. One report indicates that breast cancers that are manifested as extensive punctate calcifications very rarely occur in this pattern in metastatically involved axillary lymph nodes. The authors suggest that such punctate densities are much more often indicative of intranodal gold deposits and that they occur almost invariably in patients with rheumatoid arthritis who have undergone prolonged chrysotherapy. This observation was confirmed in one patient and suspected in three others with similar clinical histories.

Radiographic findings of pulmonary coccidioidomycosis in neonates and infants.

Radiographic findings in four recent cases of pulmonary coccidioidomycosis are reported. Focal consolidation and diffuse nodular densities were observed at one point during the course of the illness in all four patients. Pleural effusion or mediastinal adenopathy was not seen. Hilar adenopathy developed in one patient after 61/2 months. Hyperaeration was noted in all patients. One patient survived the pneumonia and had subsequent clearing of the infiltrates. Cavitation was not seen in any of the patients. The insidious onset and nonspecific and often misleading clinical and laboratory findings in pulmonary coccidioidomycosis infection in neonates and infants may seriously delay the correct diagnosis in this highly fatal disease. A knowledge of the characteristic radiographic manifestations of this pulmonary disease may be helpful to the clinician.

Does transplacental spread of coccidioidomycosis occur? Report of a neonatal fatality and review of the literature.

A neonatal death due to unsuspected coccidioidomycosis was studied. A critical review of the 12 neonatal fatalities and two survivals now reported strongly opposes the concept of transplacental spread. Associated with 35 maternal fatalities in the literature are 16 cases of placentitis and five neonatal deaths; none of the neonatal deaths, however, were associated with placentitis. Three of these five had predominantly intrathoracic disease, as did those neonates whose rapid deaths were unassociated with maternal coccidioidomycosis. Transpartum aspiration of infected decidua or postpartum inhalation is the probable initial pathogenic event in neonatal coccidioidomycosis.